Salford Clinical Commissioning Group, Salford Civic Centre, Salford, M27 5AW, UK.
Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
BMC Emerg Med. 2021 May 1;21(1):55. doi: 10.1186/s12873-021-00450-2.
The response to the COVID-19 pandemic in the United Kingdom included large scale changes to healthcare delivery, without fully understanding the potential for unexpected effects caused by these changes. The aim was "to ascertain the characteristics of patients, uncertainty over diagnosis, or features of the emergency response to the pandemic that could be modified to mitigate against future excess deaths".
Review of the entire pathway of care of patients whose death was registered in Salford during the 8 week period of the first wave (primary care, secondary care, 111 and 999 calls) in order to create a single record of healthcare prior to death. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale. The panel identified themes using a structured judgement review format.
There were 522 deaths including 197 in hospital, and 190 in care homes. 51% of patients were female, 81% Caucasian, age 79 ± 9 years. Dementia was present in 35%, COVID-19 was cause of death in 44%. Healthcare contact prior to death was most frequently with primary care (81% of patients). Forty-six patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9). Fewer than half of NHS 111 calls were answered during this period. 18% of deaths contained themes consistent with some degree of avoidability. In people aged ≥75 years who lived at home this was 53%, in care home residents 29% and in patients with learning disability 44% (n = 9). Common themes were; delays in patients presenting to care providers (10%), delays in testing (17%), avoidable exposure to COVID-19 (26%), delays in provider response (5%), and sub-optimal care (11%). For avoidability scores of 2 or 3 (indicating more than 50% chance of avoidability), 44% of cases had > 2 themes.
The initial emergency response had unforeseen consequences resulting in late presentation, sub-optimal assessments, and delays in receiving care. Death in more vulnerable groups was more likely to display avoidability themes.
英国对 COVID-19 大流行的应对措施包括对医疗保健服务进行大规模调整，但并未充分了解这些变化可能带来的意外影响。目的是“确定可能导致未来超额死亡的患者特征、诊断不确定性或大流行应急响应的特征，以便加以修改”。
回顾在第一波期间（初级保健、二级保健、111 和 999 电话）在索尔福德死亡登记的所有患者的整个护理途径，以便在死亡前创建一个单一的医疗记录。一个专家小组根据国家死亡率病例审查计划对可避免性进行了评估。该小组使用结构化判断审查格式确定了主题。
共有 522 人死亡，其中 197 人在医院，190 人在护理院。51%的患者为女性，81%为白种人，年龄为 79±9 岁。35%的患者患有痴呆症，44%的患者死于 COVID-19。死亡前与医疗保健的接触最常发生在初级保健（81%的患者）。有 46 名患者（9%）取消了医疗预约（中位数为 1 次取消，范围为 1-9）。在此期间，不到一半的 NHS 111 电话得到接听。18%的死亡病例包含一定程度可避免性的主题。在年龄≥75 岁的居家患者中，这一比例为 53%，在护理院居民中为 29%，在有学习障碍的患者中为 44%（n=9）。常见的主题是：患者向护理提供者就诊的延迟（10%），检测的延迟（17%），可避免的 COVID-19 暴露（26%），提供者响应的延迟（5%），以及护理不足（11%）。对于可避免性评分为 2 或 3（表示可避免性超过 50%的可能性）的病例，44%的病例有>2 个主题。
最初的应急响应产生了意想不到的后果，导致就诊延迟、评估不足以及接受护理的延迟。在更脆弱的群体中死亡更有可能显示出可避免性主题。
